Cardiologist urges doctors to take patients’ wishes more into consideration

Initiatives in both the US and the UK look set to vastly increase the number of people deemed eligible for treatment with statins. While some seem to have welcomed these moves, there has been a lot of dissent too. Some believe that statins already have an unfavourable risk/benefit profile for people judged to be at low risk of having a heart attack or stroke. For those that hold this view (I am one of them), giving statins to people at even lower risk can seem crazy.

Take a casual surf online regarding these issues and you perhaps notice that many people opposed to ‘statination’ feel they have suffered at the hands of the medical profession and its ‘liberal’ use of statins. Others have never taken statins, but have come to the conclusion that the benefits of statins are likely outweighed by their risks, for them, and they therefore do not want to take them. Nevertheless, these individuals sometimes feel they are being put under inordinate pressure by their doctors to ‘comply’. Some will have been given dire warnings about the supposed risks of declining statins.

Sometimes feel compelled to remind individuals, though, doctors cannot force patients to take medication they do not want to take. Ultimately, once statins have been offered, the decision about whether the medication is taken or not is usually in the hands of the patient alone.

I was reminded of this fact while reading an opinion piece this week in the Journal of the American Medical Association, written by Yale University cardiologist and professor of medicine Harlan Krumholz [1]. The piece explores some of the issues and controversies surrounding the recent cholesterol guidelines in the US (as well as issues concerning the guidelines related to blood pressure management).

In particular, Professor Krumholz makes the point that guidelines “should inform but not dictate, guide but not enforce, and support but not restrict.”

Professor Krumholz goes on to write that:

Guidelines can provide options and recommendations for those seeking to improve the quality and quantity of their lives. They can indicate strategies that are, in the opinion of the experts, outside of evidence and unworthy of pursuit. They can highlight points of uncertainty. But they should not reduce physicians to automatons and patients to passive recipients of guideline dictums.

Professor Krumholz makes some (what I believe to be) very sensible recommendations regarding the way forward, including an emphasis on producing evidence that who is likely to benefit most from treatment, and what trade-off risks there are too.

Interestingly, though, Professor Krumholz makes a strong call for the patient to be involved more in the decision making process. Under the recommendation to “Strengthen the Patient’s Voice”, he writes:

Finding ways to ensure that patients have agency over their decisions in ways that are genuine will be increasingly important. Patients and physicians need to work together, with the clinicians in a position to assist decisionsbut not impose choices. Physicians need to invite discussion, support informed choice, and instill patients with the courage to participate. Patients need to know that the medical facts alone are insufficient to determine what is right for them. Their context, preferences, values, and goals must be part of the decision if the final choice is to be in alignment with their best interests.

I have to admit, it’s not often that I read a comment pertaining to statin therapy from a cardiologist who does not seem frothingly enthusiastic about these drugs. Professor Krumholz should be commended for his seeming ability to think independently, and for his focus not on the supposed ‘need’ for treatment, but the needs and desires of real people.

References:

1. Krumholz HM. The New Cholesterol and Blood Pressure Guidelines Perspective on the Path Forward JAMA published on line 29 March 2014

20 Responses to Cardiologist urges doctors to take patients’ wishes more into consideration

This is great! I think my worry has always been that on the NHS if I refused to take them that my doctor could refuse to treat me. He has been fairly reasonable about everything else, but he is a statin freak! I have been controlling my blood sugar with diet and my pressure has been ok, but he is so stubborn about the cholesterol thing! I printed out one of your articles about Cholesterol awhile back and gave it to him, but he wasn’t impressed….sigh…

Yes Dr Briffa, and the persistent, invasive phone calls and letters from the GP urging flu jabs, shingles jabs, routine bloods, B/P readings, eye screening, occult faecal tests, lung function tests, etc etc…..crickey…..they do so intrude on the precious time needed for my gym visits, outdoor walks, healthy food preparation and jolly hols…..I see…that’s the ploy…..keep the oldies busy in the surgery, and then they can’t spend time keeping fit and healthy…
GET THEM HOOKED ON THE PHARMACEUTICAL MERRY-go-ROUND, and leave the practice Nurse to fill in those lucrative ticky boxes , whilst answering tricky questions that these awkward, outspoken, educated silver surfers conjure up from that revealing, internet thingy.
Look at it this way Dr GP, please understand……whilst I feel fit and healthy, have no worrying symptoms or incapacitating injuries, I really do not need pestering to inform me that I may shave a day or two off my life expectancy! I need every hour to enjoy the finite time left….yes, you are correct…i am going to die…..but, goodness me, leave me to spend any time left just how I wish, and not tied to your timetable.
We would pour scorn on astronomers who would dare to suggest we MAY get run over by a number 39 bus sometime in the next 10 years …..well, I put these infernal diagnostic tests in about the same category.
Yoga lesson calling….oh dear me….I might slip on that nice polished floor….better stay put with my knee rug and slippers.

Well said Jennifer………….. I believe you have just put the whole thing into perspective ….choices is what it is all about.
And call someone with a crystal ball making predictions a kook but call someone with a degree and a computer making similar predictions and they are experts??
I think any prediction is still just a guess, no one can determine another’s fate or say what is good for them.
So what is wrong with death? We all end up there eventually and living in joy doing what you love doing is way better than living in fear of “the end”. Crikey sometimes I think there are more dead people walking around in physical than any we have seen off to non-physical.

There are some U.S. cardiologists who are quite skeptical about statins, but this news doesn’t seem to have filtered down to the Primary Care Physician who most of us see first. In the States it’s often the PCP who’s prescribing these meds, on the basis of routine fasting-level blood tests for cholesterol. My doctor has a terror about cholesterol. She never updated her knowledge re: the benefits of fats in the diet and still insists that saturated fat is bad for you and that high cholesterol (which isn’t really high) will kill you. I don’t know if the latest huge study demonstrating no risk from saturated fat had any effect on her; she seems set in her ways. Everyone I know has a primary doctor whose views are the same. Several friends of mine who take statins are understandably terrified about their heart attack risk because of slightly elevated cholesterol numbers, and they’re not interested in educating themselves further, despite side effects like exhaustion and brain fog.

Prof. Krumholz’s intentions are great, and I hope he has some influence. Unfortunately, the statins paradigm has drilled its way into the brains of both doctors and consumers to such a degree that it’s going to take many more years of evidence and the loud voices of cardiologists to curb their use.

I personally have not experienced a hard sell for a drug. I’ve heard of it happening from others, but it has not happened to me personally. The strangest push of a pharmaceutical that I can recall occurred to me when I visited a new physician about taking an anti-depressant. At that time I had read that anti depressants can cause constipation, or as I jokingly call it the dream disease. I have a sever, debilitating GI condition that far to often leads to the other end result, D. So I go the appointment. She was a doctor recommended by another doctor to see about sever GI conditions.

I get there and I do my sales job mentioning my desire to take an anti-depressant in hopes that it would help me control my GI issue. Oh, I can help! she says. She then went over to a drawer, pulled out a couple sample boxes of an anti-depressant and handed them to me. She then went on to explain that it would take two weeks before I noticed the drug helping. She added that this anti-depressants was different from how many others work in the body. These samples she gave worked on raising dopamine levels (I believe) while most others work by raising some other brain mood altering chemical.

She then went on to explain side effects. The main side effect that jumped out in my mind, setting off alarm signals, is that the samples she gave me can sometimes cause diarrhea! (No mention about constipation!) I laughed when she said that. I then joked and laughed that this would be a new experience, having diarrhea but being happy about it.

The doctor was not amused. No she was not. I bombed with that one. I could see her face pucker up, and she became quite agitated. Crazy came to mind. She needed the anti-depressant more than I did! I did hand them back to her. (Maybe stressed might be a better description of her at that time). Regardless, next thing that I know she says I needed a liver biopsy. No reason given why. She set up the appointment. I left, with my father, he was in the room with me at that appointment, not intending to follow through on the biopsy. Happily a few days later the hospital called saying I didn’t need a liver biopsy. Strange appointment that one. Never saw that doctor again.

I imagine with the new statin guidelines that a soft sell will be used more often. In America we of course have our newer health care system. With it comes a stipulation saying that those with high cholesterol, what ever that is determined to be, can be penalized and charged higher insurance rates. Imagine those with higher cholesterol will be given statins automatically. Those with low cholesterol levels might hear a mention that he/she needs to be careful. If their cholesterol levels happen to rise to high, a penalty kicks in, insurance rates go up. A statin might be able to avoid that from happening. That is just my guess of what some might see.

All credit to my previous GP (I have since moved to a different part of the country) – a few years ago, I asked her if I should have a cholesterol test (I knew no better then!) and she said no, I didn’t need one unless I had a family history of high cholesterol. Good for her!

Does turning down medication have further repercussions? Let’s say you have high cholesterol and notify the travel company accordingly, go on holiday and have a heart event. The travel insurance company then contact your GP and take from the notes that you turned down the ‘opportunity’ to take a statin.

Is the travel company then entitled to deny the claim as they could allege you contributed directly to your heart event?? I know it sounds far fetched to a group such as this but where does one stand when turning down medication from a GP.

Matthew, you have raised a very important point. I ‘went it alone’ last April, after my GP had a dicky fit when I suggested that I wanted to come off all meds. The response I received was just so contrary to the type of relationship we had enjoyed for 15 years, and I was quite taken aback, and will never return to that particular GP unless no one else is available. So….here I am 12 months down the line….fit and healthy as not experienced during 10 years of multiple medications…BUT not attending diabetic clinics etc, etc, …I think my new found health status is all down to a complete change in diet and lifestyle that i am now following with the likes of Dr Briffa, and certainly in opposition to the NHS guidelines prescribed at the surgery. BUT, when I went abroad in February, it caused me much angst as to what would happen if I was poorly?
I seem to be in a difficult situation if I fail to strictly adhere to “guidelines”, which I do not agree with, and I wish I knew how to get round the problem. If the GP point blank refuses to even discuss the matter, just what am I supposed to do? I am contrained by geography to keep with the same surgery, and no matter which Dr I see, it is the same Practice Nurse i get sent to, who religiously follows the NHS dogma, again, without any discussion. I am between a rock and a hard place. Fortunately, I am now in excellent health,….but…..but….but…what if? I am getting older…and things do change, so where do I turn to?

Dear Friends, couldn’t you just pick up the prescription and pretend you’re taking the medication (and of course pack the pills when you go abroad). Terrible waste of money, I know, but the NHS wastes so much already I don’t suppose your discarded pills (statins, anyway) would make that much difference.

Ya know Dave, it’s like they’re all the Stepford medics. When you come with a legitimate curved ball, their heads start spinning around. Sorry that I sound so fragile and aggressive but my son’s chest got slashed up and I hve to hear the same old story everywhere.

Okay, I have written to every single cardiologist and heart foundation to try and find a thoracic surgeon who promotes LCHF. (I do know of Dr. Donald Miller) but somewhere tucked away on the internet I also came across THIS guy, who just like Tim Noakes apologises for always having gone the low fat route. He’s at http://thecureforheartdisease.net/articles1-p2.php – he is a thoracic surgeon and for my people with FH that’s what I’m looking for. Just a pity he’s in the states and not one of his ilk in South Africa, where I live, will give me an answer. We HAVE to see cardiologists because of our ailment, but I refuse the low fat nonsense they keep badgering me with. Oh well…

While I hate to rain on your parade, because I have the same views you do with regard to LCHF, the thoracic surgeon you link to above (Dwight C. Lundell), no longer practices medicine in the US because his license was revoked. This gives him more time to publicize his views on heart disease, but doesn’t do much for his credibility.

The board established that the physician failed to maintain adequate medical records in the physician’s operative report of a patient. The physician also failed to cool the patient’s anterior wall which was harmful to the patient’s health and resulted in the death of the patient. The board also established that another patient died as a result of the physician’s failure to order blood type and cross match the patient and obtain O-negative blood prior to proceeding with surgery. The physician also failed to initiate insulin infusion during another patient’s surgery and monitor the patient’s sternal wound closely after the physician saw evidence of infection. The board also took into consideration the physician’s ten year disciplinary history with the board.

Action Taken:

The board has Revoked the physician’s license to practice allopathic medicine in the State of Arizona and shall pay hearing administrative costs.”

Thank you so much Rita. CANNOT believe this. Here I find a cardiologist and I get this Eureka feeling and then that’s also another damp squib.
I tell ya I DO want a nice cardiologist. Can’t find them. They don’t even have to know about my diet (it’s my biz after all), but because of our ailment (which I have now grown to hate totally because my son was SO hurt by it) we need cardiologists in our lives. Honest to G-d I just want a nice doctor. I don’t need him to be my shrink, I need him to just answer when I ask something and NEVER to shrug ever. Why are gynacologists so nice? So what’s the diffs. I don’t understand what a lipid specialist is. When I do research them it’s sweepingly a case of STATINS for YOU madam and low fat diet. So what is it that makes them a specialist since there is NO further science for us since when Cholesterol was discovered. Do you know what, I wish these doctors (when we’re not physically ill) will call us clients instead of patients. Perchance then we won’t have to have our hearts beat even faster when we enter that dreaded room.

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